Healthcare Provider Details

I. General information

NPI: 1356828230
Provider Name (Legal Business Name): JAMIE HITRO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 05/07/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W NORTH AVE
CHICAGO IL
60610
US

IV. Provider business mailing address

1700 E HIGGINS RD STE 600
DES PLAINES IL
60018-5621
US

V. Phone/Fax

Practice location:
  • Phone: 312-643-5606
  • Fax:
Mailing address:
  • Phone: 847-653-0130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006622
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: